Eyelid Trauma

Eyelid trauma includes blunt injury, lacerations, burns, bites, and avulsions.

• Mechanisms: assault, road traffic collisions, sports, dog bites (especially children), falls, fireworks.
• Always consider associated injury: globe rupture, hyphaema, retinal injury, orbital fracture, lacrimal system injury and intracranial injury.
• The eyelid is rich in blood supply and heals well, so primary repair within 24 hours (up to 48 to 72 hours with care) gives good results.

• Periocular ecchymosis and swelling (the swelling can hide the globe), subconjunctival haemorrhage.
• Blunt injury: lid oedema, haematoma, lid margin tears, canalicular avulsion by horizontal traction (the medial canthal tendon avulses).
• Lid margin or deep wound with levator injury causes ptosis. Fat prolapse implies septal breach and deep injury.
• Bite wounds: crush and contamination; human and dog bites risk infection.
• Burns: scarring, lagophthalmos, exposure keratopathy.
• Warning signs of globe or orbital injury: reduced vision, pupil abnormality, limited motility, enophthalmos, hypoglobus, crepitus.

• Full ocular examination first: acuity, pupils (relative afferent defect), motility, intraocular pressure only if open globe excluded, dilated fundus.
• Gentle lid retraction to examine the globe. Do not press on a suspected ruptured globe.
• Document wound depth, tissue loss, lid margin involvement, canalicular involvement, levator and medial canthal tendon status. Tendon avulsion: bowstringing (the medial canthus is pulled laterally on traction).
• CT orbits and brain (axial and coronal, 1 to 2 mm cuts) for deep wound, suspected fracture, or retained foreign body (wood, glass, metal). MRI is avoided with possible metallic foreign body.
• Photographs and medicolegal documentation for assault.

• Resuscitation and tetanus prophylaxis (tetanus toxoid 0.5 mL intramuscularly if immunisation incomplete, plus tetanus immunoglobulin 250 to 500 units for dirty wounds).
• Irrigate wounds with saline; remove foreign material; debride only clearly necrotic tissue because lid tissue is precious.
• Antibiotics for bites and contaminated wounds: amoxicillin clavulanate 625 mg orally three times daily for 5 to 7 days (children 15 mg/kg of the amoxicillin component three times daily). Add rabies assessment for animal bites.
• Repair within 24 hours where possible. Cold compresses and head elevation. Intraocular pressure and retrobulbar bleeding warrant urgent decompression.
• Repair principles: align the lid margin at the grey line with a 6-0 silk suture, close the tarsus with partial thickness 6-0 absorbable sutures, then close orbicularis and skin with 6-0 to 7-0 sutures. Keep knots away from the cornea. Repair a canalicular laceration within 24 to 48 hours over a silicone stent, which stays in for 3 to 6 months.
• Burns: lubrication, early skin grafting for full thickness loss to prevent cicatricial ectropion and exposure; tarsorrhaphy temporary if needed.
• Follow up for scarring, canalicular stenosis, ptosis and lid malposition at 6 weeks and 3 months.